Medicare Supplement Insurance Approved Policies List (PI-010)

Medicare Supplement InsuranceApproved Policies List

2017

For more information on health insurance call:MEDIGAP HELPLINE

1-800-242-1060

This is a statewide toll-free number set up by the Wisconsin Board on Aging and Long Term Care and funded by the Office of the Commissioner of Insurance to answer questions about health insurance and other health care benefits for the elderly. It has no connection with any insurance company.

State of WisconsinOffice of the Commissioner of Insurance

P.O. Box 7873Madison, WI 53707-7873

OCI's Web Site:oci.wi.gov

Deaf, hearing, or speech impaired callersmay reach OCI through WI TRS.

PI-010 (R 02/2017)

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State of Wisconsin, Office of the Commissioner of InsuranceMedicare Supplement Insurance Approved Policies List

The mission of the Office of

the Commissioner of Insurance . . .

Leading the way in informing and protecting

the public and responding to their insurance needs.

If you have a specific complaint about your insurance, refer it first to the insurance company or agent involved. If you do not receive satisfactory answers, contact the Office of the Commissioner of Insurance (OCI).

To file a complaint online or to print a complaint form:OCI's Web Page

oci.wi.gov

Phone(608) 266-0103 (In Madison)

or1-800-236-8517 (Statewide)

Mailing AddressOffice of the Commissioner of Insurance


Electronic [email protected]

Please indicate your name, phone number, and e-mail address.

Deaf, hearing, or speech impaired callers mayreach OCI through WI TRS

This list contains information on Medicare supplement insurance policies approved by the Office of the Commissioner of Insurance (OCI). It includes only policies currently being sold in Wisconsin. The companies shown in this list have agreed to be listed. Group policies sold through employers are not included in this list. There are companies that currently sell Medicare supplement insurance policies approved by OCI that have chosen not to be included in the list.

Premiums for the policies on the list are as of January 1, 2017, unless noted, and may change throughout the year. This list is updated on an annual basis.

For more detailed information on Medicare and Medicare supplement insurance, visit our Web site or contact OCI and request a copy of the publication Wisconsin Guide to Health Insurance for People with Medicare.

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Table of Contents

Page

Definitions ........................................................................................................... 5

Individual Medicare Supplement Policies—Traditional Insurers ................... 6

Aetna Life Insurance Company ....................................................................... 7 American Continental Insurance Company..................................................... 9 American Republic Corp. Insurance Company ............................................... 11 American Republic Insurance Company ......................................................... 20 American Retirement Life Insurance Company .............................................. 30 Blue Cross Blue Shield of Wisconsin .............................................................. 32 Central States Indemnity Company of Omaha................................................ 35 Colonial Penn Life Insurance Company .......................................................... 37 Combined Insurance Company of America..................................................... 42 Gerber Life Insurance Company ..................................................................... 44 Globe Life and Accident Insurance Company ................................................. 47 Government Personnel Mutual Life Insurance Company ............................... 48 Greek Catholic Union of the U.S.A.................................................................. 51 Gundersen Health Plan, Inc. ........................................................................... 53 Humana Insurance Company ......................................................................... 56 Individual Assurance Company ....................................................................... 69 Manhattan Life Insurance................................................................................ 71 Medico Corp Life Insurance Company ............................................................ 73 Mutual of Omaha Insurance Company ........................................................... 77 Order of United Commercial Travelers of America.......................................... 79 Pekin Life Insurance Company ....................................................................... 81 Physicians Mutual Insurance Company .......................................................... 84 Polish Falcons of America ............................................................................... 96 Reserve National Insurance Company ........................................................... 99 Security Health Plan of Wisconsin, Inc. .......................................................... 102 Standard Life and Accident Insurance Company ............................................ 104 State Farm Mutual Automobile Insurance Company....................................... 109 Thrivent Financial for Lutherans...................................................................... 111 Unified Life Insurance Company ..................................................................... 115 United American Insurance Company............................................................. 117 Western Catholic Union .................................................................................. 119 Wisconsin Physicians Service Insurance Corporation .................................... 122

Group Medicare Supplement Policies—Traditional Insurers ......................... 127

Aetna Life Insurance Company ....................................................................... 128 UnitedHealthcare Insurance Company ........................................................... 130

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Medicare Supplement Policies—Medicare Select ........................................... 133

Dean Health Plan, Inc. .................................................................................... 134 Group Health Cooperative of South Central Wisconsin .................................. 135 Health Tradition Health Plan ........................................................................... 136 MercyCare HMO, Inc. ..................................................................................... 137 Physicians Plus Insurance Corporation .......................................................... 138 Security Health Plan of Wisconsin, Inc. .......................................................... 139 Unity Health Plans Insurance Corporation ...................................................... 140

Medicare Cost Insurance ................................................................................... 141

HealthPartners Insurance Company ............................................................... 142 Medica Insurance Company ........................................................................... 143 Medical Associates Clinic Health Plan of Wisconsin ....................................... 144

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DefinitionsAttained age: As you age your premiums will change to meet your age range and your premiums will become higher.

Health history: Health questions may be asked if you are enrolling at a time other than the open enrollment period. Questions may ask for limited information or may ask for detailed information about your health.

Issue age: Premiums are set at the age you are when you buy the policy and will not increase because you get older. Premiums may increase for other reasons.

Open enrollment period: A one-time-only six-month period when you can buy any Medicare supplement policy you want that is sold in Wisconsin. It starts when you sign up for Medicare Part B and you are age 65 or older. You cannot be denied coverage or charged more due to present or past health problems during this time period.

Preexisting condition: A medical condition diagnosed or treated up to six months prior to the purchase of an insurance policy. Medicare supplement policies may impose up to a 180-day waiting period before coverage for that condition begins.

Tobacco rates: If you use tobacco, an insurance company may charge you more for your insurance policy. However, this higher rate cannot be applied if you are enrolling during your open enrollment period.

Waiting period: The time between the effective date of your Medicare supplement insurance policy and the date the insurance company or Medicare health plan is required to begin paying benefits for preexisting conditions. Preexisting waiting periods may not last longer than six months.

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INDIVIDUAL MEDICARE SUPPLEMENT POLICIES—TRADITIONAL INSURERS

State of Wisconsin, Office of the Commissioner of InsuranceMedicare Supplement Insurance Approved Policies List Individual Policy, Traditional Insurer

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Aetna Life Insurance Company800 Crescent Centre Drive, Suite 200

Franklin, TN 37067(www.aetnaseniorproducts.com)

Consumer Service Telephone No. 1-888-624-6290

Form No. GR-11613-WI 01 First-Year Commission: 17%

Waiting Period: None Premiums are based on attained age.

Area 1: Zip Codes 530-532, 534Area 2: Rest of State

Annual Premium - Basic Policy Annual Premium - All Options

Area 1 Area 1 Age Male Female Age Male FemaleUnder 65 $6,822.00 $6,305.00 Under 65 $8,111.00 $7,579.00 65 1,602.00 1,466.00 65 2,051.00 1,915.00 70 1,972.00 1,810.00 70 2,533.00 2,366.00 75 2,324.00 2,134.00 75 3,035.00 2,836.00 80 2,555.00 2,348.00 80 3,488.00 3,260.00 85 2,640.00 2,427.00 85 4,100.00 3,832.00

Area 2 Area 2Under 65 $5,932.00 $5,483.00 Under 65 $7,071.00 $6,609.00 65 1,393.00 1,275.00 65 1,802.00 1,684.00 70 1,715.00 1,574.00 70 2,221.00 2,076.00 75 2,021.00 1,856.00 75 2,658.00 2,485.00 80 2,222.00 2,042.00 80 3,052.00 2,854.00 85 2,296.00 2,110.00 85 3,584.00 3,350.00

Annual Premium - Optional BenefitsPart A Deductible ($1,316): Area 1 Area 2 Age Male Female Male Female Under 65 $1,047.00 $1,032.00 $ 910.00 $ 897.00 65 207.00 207.00 180.00 180.00 70 319.00 314.00 277.00 273.00 75 469.00 460.00 408.00 400.00 80 691.00 670.00 601.00 583.00 85 1,218.00 1,163.00 1,059.00 1,011.00

Part B Deductible ($183): $145.00 for all ages, all areas

Rates effective January 2017


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Aetna Life Insurance Company (continued)

Part B Excess Charges: Area 1: $53.00 for all ages Area 2: $46.00 for all ages

Additional Home Health Visits: Area 1: $22.00 for all ages Area 2: $19.00 for all ages

Foreign Travel Emergency: Area 1: $22.00 for all ages Area 2: $19.00 for all ages

Part B copayment or coinsurance rider offered.Rates for tobacco users are higher outside of open enrollment period.Different premiums for each age between age 65 and 85.Discount offered for Electronic Funds Transfer (EFT) premium payment.


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American Continental Insurance Company800 Crescent Centre Drive, Suite 200



Form No. ACIMSP14BC First-Year Commission: 26%


Area 1: Zip Codes 530-534Area 2: Rest of State




Annual Premium - Optional BenefitsPart A Deductible ($1,316): Area 1 Area 2 Age Male Female Male Female Under 65 $1,070.00 $930.00 $930.00 $809.00 65 247.00 215.00 215.00 187.00 70 335.00 291.00 291.00 253.00 75 444.00 385.00 386.00 335.00 80 595.00 516.00 517.00 449.00 85 748.00 651.00 650.00 566.00




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American Continental Insurance Company (continued)Part B Excess Charges: Area 1 Area 2 Age Male Female Male Female Under 65 $286.00 $248.00 $249.00 $216.00 65 79.00 70.00 69.00 61.00 70 93.00 81.00 81.00 70.00 75 107.00 93.00 93.00 81.00 80 118.00 102.00 103.00 89.00 85 129.00 113.00 112.00 98.00



Part B copayment or coinsurance rider offered.Rates for tobacco users are higher outside of open enrollment period.Different premiums for each age between age 65 and 85.Policy fee or administrative fee charged with initial enrollment.Multi-policy household discount offered.


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American Republic Corp. Insurance CompanyP.O. Box 14510

Des Moines, IA 50306(www.americanenterprise.com)


Form No. A3103AC-WI First-Year Commission: 15%


Area 1: Zip Codes 531, 532Area 2: Zip Code 534Area 3: Zip Code 537Area 4: Zip Codes 545, 548Area 5: Zip Code 546Area 6: Rest of State


Area 1 Area 1 Age Male Female Age Male Female Under 65 $4,534.81 $3,942.55 Under 65 $5,458.73 $4,772.31 65 2,267.41 1,971.27 65 2,820.80 2,477.57 70 2,518.59 2,189.24 70 3,111.86 2,730.20 75 2,998.93 2,565.56 75 3,668.80 3,166.33 80 3,438.17 2,892.88 80 4,177.89 3,545.81 85 3,906.59 3,272.49 85 4,720.82 3,985.84

Area 2 Area 2 Under 65 $4,867.64 $4,231.91 Under 65 $5,842.71 $5,106.13 65 2,433.82 2,115.95 65 3,012.78 2,644.49 70 2,703.44 2,349.92 70 3,325.12 2,915.57 75 3,219.03 2,753.85 75 3,922.73 3,383.56 80 3,690.51 3,105.20 80 4,469.01 3,790.77 85 4,193.31 3,512.67 85 5,051.61 4,262.94




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American Republic Corp. Insurance Company (continued)





Annual Premium - Optional BenefitsPart A Deductible ($1,316): Area 1 Area 2 Area 3 Age Male Female Male Female Male FemaleUnder 65 $696.91 $605.87 $748.06 $650.33 $652.15 $566.96 65 348.46 302.93 374.03 325.17 326.08 283.48 70 387.02 336.51 415.43 361.20 362.17 314.90 75 460.98 394.28 494.81 423.22 431.37 368.96 80 528.43 444.64 567.21 477.28 494.49 416.09 85 600.42 503.02 644.49 539.94 561.86 470.72


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Area 4 Area 5 Area 6 Age Male Female Male Female Male FemaleUnder 65 $594.61 $516.93 $562.65 $489.14 $626.58 $544.72 65 297.31 258.47 281.32 244.57 313.29 272.36 70 330.21 287.11 312.46 271.68 347.96 302.55 75 393.31 336.40 372.16 318.32 414.46 354.49 80 450.86 379.37 426.62 358.98 475.10 399.77 85 512.28 429.18 484.74 406.11 539.83 452.26


Part B Excess Charges: All Areas Age Male Female Under 65 $24.48 $21.36 65 12.24 10.68 70 13.56 11.76 75 16.20 13.80 80 18.60 15.60 85 21.12 17.64

Additional Home Health Care: Age: Under 65 $12.48 65-85 6.24

Foreign Travel Emergency: Age: Under 65 $ 7.20 65-85 3.60

Rates for tobacco users are higher outside of open enrollment period.Different premiums for each age between age 65 and 85.Multi-policy household discount offered.Part A Deductible (50%) offered.


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Form No. A3120AC-WI, A3121AC-WI First-Year Commission: 15% 50% Cost-Sharing Plan 25% Cost-Sharing PlanWaiting Period: None Premiums are based on attained age.


Annual Premium - 50% Cost-Sharing Plan

Annual Premium - Basic Policy Annual Premium - All Options Area 1 Area 1 Age Male Female Age Male Female Under 65 $2,566.56 $2,231.59 Under 65 $2,579.04 $2,244.07 65 1,283.28 1,115.79 65 1,289.52 1,122.03 70 1,425.64 1,239.23 70 1,431.88 1,245.47 75 1,697.31 1,452.11 75 1,703.55 1,458.35 80 1,946.02 1,637.35 80 1,952.26 1,643.59 85 2,211.15 1,852.23 85 2,217.39 1,858.47




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Area 4 Area 4 Under 65 $2,189.82 $1,904.02 Under 65 $2,202.30 $1,916.50 65 1,094.91 952.01 65 1,101.15 958.25 70 1,216.37 1,057.33 70 1,222.61 1,063.57 75 1,448.16 1,238.95 75 1,454.40 1,245.19 80 1,660.37 1,397.00 80 1,666.61 1,403.24 85 1,886.58 1,580.34 85 1,892.82 1,586.58



You will pay 50% of the cost-sharing of some covered services until you reach the calendar year out-of-pocket limit of $5,120 which will increase each year for inflation. Once you reach the annual limit, the policy pays 100% of your Medicare copayment and coinsurance for the rest of the calendar year.


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Annual Premium - Optional Benefits


Rates for tobacco users are higher outside of open enrollment period.Different premiums for each age between age 65 and 85.Multi-policy household discount offered.


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Form No. A3098AC-WI First-Year Commission: 15%



Annual Premium - High Deductible Plan

Area 1 Area 2 Age Male Female Age Male Female Under 65 $1,768.27 $1,600.14 Under 65 $1,898.05 $1,717.58 65 884.13 800.07 65 949.02 858.79 70 982.11 888.48 70 1,054.20 953.69 75 1,169.38 1,041.10 75 1,255.20 1,117.52 80 1,340.55 1,174.01 80 1,438.94 1,260.18 85 1,523.17 1,328.09 85 1,634.97 1,425.56

Area 3 Area 4 Under 65 $1,654.71 $1,497.38 Under 65 $1,508.71 $1,365.26 65 827.35 748.69 65 754.35 682.63 70 919.04 831.42 70 837.95 758.06 75 1,094.28 974.24 75 997.72 888.28 80 1,254.46 1,098.62 80 1,143.77 1,001.68 85 1,425.36 1,242.80 85 1,299.59 1,133.14

Area 5 Area 6 Under 65 $1,427.59 $1,291.85 Under 65 $1,589.82 $1,438.66 65 713.80 645.93 65 794.91 719.33 70 792.90 717.31 70 883.00 798.82 75 944.08 840.52 75 1,051.37 936.04 80 1,082.28 947.83 80 1,205.27 1,055.54 85 1,229.72 1,072.22 85 1,369.46 1,194.06



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You must pay a calendar year deductible of $2,200. This deductible consists of expenses that would ordinarily be paid by the policy. This includes the Medicare deductibles for Part A and Part B but does not include the separate foreign travel emergency deductible.



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American Republic Insurance CompanyP.O. Box 1

Des Moines, IA 50306(www.americanrepublic.com)


Form No. A3158AC-WI First-Year Commission: 12.5%


Area 1: Zip Codes 531, 532Area 2: Zip Code 534Area 3: Zip Codes 530, 535-537, 539, 541, 543, 549Area 4: Zip Codes 545, 548Area 5: Zip Code 540Area 6: Zip Code 546Area 7: Rest of State







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American Republic Insurance Company (continued)







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Annual Premium - Optional BenefitsPart A Deductible ($1,316): Area 1 Area 2 Area 3 Age Male Female Male Female Male FemaleUnder 65 $981.99 $770.49 $1,048.73 $822.86 $905.72 $710.65 65 302.74 260.84 323.31 278.56 279.22 240.58 70 323.23 276.49 345.20 295.28 298.13 255.02 75 400.99 348.02 428.24 371.67 369.84 320.99 80 478.23 417.87 510.73 446.27 441.09 385.42 85 572.30 476.11 611.19 508.46 527.85 439.13

Area 4 Area 5 Area 6 Age Male Female Male Female Male FemaleUnder 65 $886.65 $695.69 $1,067.80 $837.82 $838.98 $658.28 65 273.35 235.51 329.19 283.63 258.65 222.85 70 291.85 249.65 351.48 300.65 276.16 236.23 75 362.06 314.23 436.03 378.43 342.59 297.33 80 431.80 377.30 520.02 454.38 408.58 357.02 85 516.74 429.88 622.31 517.71 488.95 406.77

Area 7 Age Male FemaleUnder 65 $934.32 $733.09 65 288.04 248.18 70 307.54 263.07 75 381.52 331.12 80 455.01 397.59 85 544.52 453.00


Part B Excess Charges: Male Female Age: Under 65 $24.48 $21.36 65 12.24 10.68 70 13.56 11.76 75 16.20 13.80 80 18.60 15.60 85 21.12 17.64



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Foreign Travel Emergency: Age: Under 65 $ 7.20 65-85 3.60

Rates for tobacco users are higher outside of open enrollment period.Different premiums for each age between age 65 and 85.Multi-policy household discount offered.Part A Deductible (50%) offered.


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Form No. A3160AZ-WI, A3159AC-WI First-Year Commission: 12.5% 50% Cost-Sharing Plan 25% Cost-Sharing PlanWaiting Period: None Premiums are based on attained age.







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Area 3 Area 3 Age Male Female Age Male Female Under 65 $3,317.40 $2,689.38 Under 65 $3,329.88 $2,701.86 65 1,056.90 945.29 65 1,063.14 951.53 70 1,121.26 994.41 70 1,127.50 1,000.65 75 1,377.55 1,239.58 75 1,383.79 1,245.82 80 1,632.64 1,478.53 80 1,638.88 1,484.77 85 1,943.59 1,674.45 85 1,949.83 1,680.69

Area 4 Area 4 Under 65 $3,247.56 $2,632.76 Under 65 $3,260.04 $2,645.24 65 1,034.65 925.39 65 1,040.89 931.63 70 1,097.65 973.48 70 1,103.89 979.72 75 1,348.55 1,213.48 75 1,354.79 1,219.72 80 1,598.27 1,447.41 80 1,604.51 1,453.65 85 1,902.67 1,639.20 85 1,908.91 1,645.44


Area 6 Area 6 Under 65 $3,072.96 $2,491.22 Under 65 $3,085.44 $2,503.70 65 979.03 875.64 65 985.27 881.88 70 1,038.64 921.14 70 1,044.88 927.38 75 1,276.04 1,148.24 75 1,282.28 1,154.48 80 1,512.34 1,369.59 80 1,518.58 1,375.83 85 1,800.37 1,551.07 85 1,806.61 1,557.31



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Form No. A3161AC-WI First-Year Commission: 12.5%




Area 1 Area 2 Age Male Female Age Male Female Under 65 $2,877.41 $2,332.68 Under 65 $3,072.96 $2,491.21 65 916.73 819.91 65 979.03 875.63 70 972.55 862.52 70 1,038.64 921.14 75 1,194.84 1,075.18 75 1,276.04 1,148.25 80 1,416.11 1,282.43 80 1,512.35 1,369.59 85 1,685.80 1,452.37 85 1,800.37 1,551.08

Area 3 Area 4 Under 65 $2,653.92 $2,151.50 Under 65 $2,598.05 $2,106.21 65 845.53 756.23 65 827.73 740.31 70 897.01 795.53 70 878.12 778.78 75 1,102.04 991.67 75 1,078.84 970.79 80 1,306.12 1,182.83 80 1,278.62 1,157.92 85 1,554.87 1,339.57 85 1,522.13 1,311.37

Area 5 Area 6 Under 65 $3,128.83 $2,536.51 Under 65 $2,458.37 $1,992.97 65 996.83 891.55 65 783.23 700.51 70 1,057.53 937.89 70 830.91 736.91 75 1,299.24 1,169.12 75 1,020.84 918.60 80 1,539.84 1,394.49 80 1,209.88 1,095.67 85 1,833.10 1,579.28 85 1,440.30 1,240.86



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Area 7 Age Male Female Under 65 $2,737.73 $2,219.45 65 872.23 780.11 70 925.34 820.65 75 1,136.84 1,022.98 80 1,347.36 1,220.18 85 1,603.97 1,381.87




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American Retirement Life Insurance Company11200 Lakeline Blvd., Suite 100

Austin, TX 78717(www.cignasupplementbenefits.com)


Form No. AR-BASC-WI First-Year Commission: 13.5% - 27%

Waiting Period: 6 Months Premiums are based on attained age.

Area 1: Zip Codes 535-549Area 2: Zip Codes 530-534




Annual Premium - Optional BenefitsPart A Deductible ($1,316): Area 1 Area 2 Age Male Female Male Female Under 65 $884.88 $769.46 $1028.93 $894.73 65 294.96 256.49 342.98 298.18 70 349.35 303.79 406.22 353.24 75 434.73 378.02 505.50 439.56 80 544.92 473.84 633.63 550.98 85 667.09 580.08 775.69 674.51




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American Retirement Life Insurance Company (continued)

Part B Excess Charges: Area 1 Area 2 Age Male Female Male Female Under 65 $58.06 $50.50 $67.51 $58.72 65 19.35 16.83 22.50 19.57 70 22.75 19.78 26.45 23.00 75 26.39 22.95 30.69 26.68 80 30.34 26.38 35.28 30.68 85 33.95 29.52 39.48 34.33

Additional Home Health Care: Area 1 Area 2 Age Male Female Male Female Under 65 $257.27 $223.71 $299.16 $260.13 65 85.76 74.58 99.72 86.72 70 102.91 89.48 119.67 104.05 75 120.07 104.40 139.61 121.40 80 137.21 119.31 159.54 138.73 85 154.36 134.23 179.49 156.08

Foreign Travel Emergency: Area 1 Area 2 Age Male Female Male Female Under 65 $42.23 $36.91 $49.34 $42.92 65 14.14 12.30 16.45 14.31 70 16.63 14.46 19.34 16.82 75 19.30 16.78 22.44 19.51 80 22.18 19.29 25.79 22.43 85 24.82 21.58 28.86 25.09



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Blue Cross Blue Shield of Wisconsin(dba Anthem Blue Cross and Blue Shield)

P.O. Box 659816San Antonio, TX 78265-9116

(www.anthem.com)


Form No. AWLP-130706348 First-Year Commission: 12%


Area 1: Kenosha, Milwaukee, Ozaukee, Racine, Washington, and Waukesha CountiesArea 2: Brown, Dane, and Outagamie CountiesArea 3: Rest of State







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Blue Cross Blue Shield of Wisconsin (continued)Annual Premium - Optional Benefits

Part A Deductible ($1,316): Area 1 Area 2 Area 3 Age Male Female Male Female Male FemaleUnder 65 $1,716.84 $1,593.96 $1,459.32 $1,354.92 $1,545.12 $1,434.60 65 352.56 327.36 299.64 278.28 317.28 294.60 70 436.68 405.12 371.16 344.40 393.00 364.56 75 530.88 493.20 451.20 419.28 477.84 443.88 80 699.72 649.68 594.72 552.24 629.76 584.76 85 699.72 649.68 594.72 552.24 629.76 584.76

Part B Deductible ($183): Age Area 1 Area 2 Area 3 Under 65 $317.16 $269.64 $285.48 65-85 163.92 139.32 147.48

Part B Excess Charges: Area 1 Area 2 Area 3 Age Male Female Male Female Male FemaleUnder 65 $407.04 $378.12 $345.96 $321.36 $366.36 $340.32 65 83.28 77.40 70.80 65.76 75.00 69.72 70 104.28 96.96 88.68 82.44 93.84 87.24 75 127.68 118.56 108.48 100.80 114.96 106.68 80 166.20 154.56 141.24 131.40 149.64 139.08 85 166.20 154.56 141.24 131.40 149.64 139.08

Additional Home Health Care: Area 1 Area 2 Area 3 Age Male Female Male Female Male FemaleUnder 65 $136.68 $126.84 $116.16 $107.76 $123.00 $114.12 65 30.24 27.96 25.68 23.76 27.24 25.20 70 36.12 33.48 30.72 28.44 32.52 30.12 75 42.96 39.84 36.48 33.84 38.64 35.88 80 57.36 53.16 48.72 45.24 51.60 47.88 85 57.36 53.16 48.72 45.24 51.60 47.88


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Blue Cross Blue Shield of Wisconsin (continued)Foreign Travel Emergency: Area 1 Area 2 Area 3 Age Male Female Male Female Male FemaleUnder 65 $203.64 $188.88 $173.04 $160.56 $183.24 $170.04 65 42.12 39.12 35.76 33.24 37.92 35.16 70 51.84 48.12 44.04 40.92 46.68 43.32 75 62.28 57.72 52.92 49.08 56.04 51.96 80 82.32 76.44 69.96 64.92 74.04 68.76 85 82.32 76.44 69.96 64.92 74.04 68.76

Part B copayment or coinsurance rider offered.Rates for tobacco users are higher outside of open enrollment period.Different premiums for each age between age 65 and 85.Multi-policy household discount offered.Discount offered for Electronic Funds Transfer (EFT) premium payment.


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Central States Indemnity Company of Omaha1212 North 96th StreetOmaha, NE 68114-2274(www.csi-omaha.com)


Form No. CSBASWI First-Year Commission: Varies


Area 1: Zip Codes 530-534Area 2: Zip Codes 535-538, 544, 549Area 3: Rest of State





Rates effective February 2017


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Central States Indemnity Company of Omaha (continued)

Annual Premium - Optional BenefitsPart A Deductible ($1,316): Area 1 Area 2 Area 3 Age Male Female Male Female Male FemaleUnder 65 $1,183.00 $1,030.00 $1,063.00 $925.00 $924.00 $805.00 65 419.00 364.00 376.00 327.00 327.00 285.00 70 500.00 434.00 449.00 390.00 390.00 339.00 75 594.00 514.00 533.00 462.00 464.00 402.00 80 673.00 587.00 604.00 527.00 526.00 459.00 85 730.00 635.00 656.00 570.00 571.00 496.00




Foreign Travel Emergency: Area 1 Area 2 Area 3 Age Male Female Male Female Male FemaleUnder 65 $117.00 $102.00 $105.00 $92.00 $92.00 $80.00 65 41.00 36.00 37.00 33.00 32.00 28.00 70 46.00 41.00 41.00 37.00 36.00 32.00 75 54.00 46.00 49.00 41.00 43.00 36.00 80 59.00 51.00 53.00 46.00 46.00 40.00 85 64.00 54.00 58.00 49.00 50.00 43.00

Part B copayment or coinsurance rider offered.Rates for tobacco users are higher outside of open enrollment period.Different premiums for each age between age 65 and 85.Policy fee or administrative fee charged with initial enrollment.Part A Deductible (50%) offered.


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Colonial Penn Life Insurance Company111 East Wacker Drive, Suite 2100

Chicago, IL 60601(https://www.bankerslife.com/products/medicare-supplement-insurance/)

Consumer Service Telephone No. 1-800-800-2254 Form No. CPL-GR-A830 First-Year Commission: 16%






Annual Premium - Optional BenefitsPart A Deductible ($1,316): Area 1 Area 2 Age Male Female Male Female Under 65 $1,113.05 $1,001.88 $1,012.03 $910.68 65 331.96 298.80 301.74 271.63 70 424.03 381.71 385.52 346.91 75 541.85 487.63 492.54 443.34 80 692.29 622.90 629.23 566.29 85 783.27 704.83 711.92 640.90




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Colonial Penn Life Insurance Company (continued)

Part B Excess Charges: Area 1 Area 2 Age Male Female Male Female All $16.25 $14.62 $14.73 $13.31

Additional Home Health Care: Area 1 Area 2 Age Male Female Male Female All $16.25 $14.62 $14.73 $13.31

Foreign Travel Emergency: Area 1 Area 2 Age Male Female Male Female All $16.25 $14.62 $14.73 $13.31

Part B copayment or coinsurance rider offered.Different premiums for each age between age 65 and 85.Part A Deductible (50%) offered.Discount offered for Electronic Funds Transfer (EFT) premium payment.


39



Consumer Service Telephone No. 1-800-800-2254 Form No. CPL-GR-A831, CPL-GR-A832 First-Year Commission: 16% 50% Cost-Sharing Plan 25% Cost-Sharing Plan









40

Colonial Penn Life Insurance Company (continued)







Different premiums for each age between age 65 and 85.Discount offered for Electronic Funds Transfer (EFT) premium payment.


41




Form No. CPL-GR-A834 First-Year Commission: 10%




Area 1 Area 2 Age Male Female Age Male Female Under 65 $2,175.25 $1,957.73 Under 65 $1,976.71 $1,779.04 65 698.39 628.69 65 634.69 571.20 70 846.21 761.67 70 768.76 691.96 75 1,026.97 924.21 75 933.16 839.88 80 1,225.08 1,102.57 80 1,113.26 1,001.99 85 1,420.13 1,278.21 85 1,290.64 1,161.48


Different premiums for each age between age 65 and 85.Discount offered for Electronic Funds Transfer (EFT) premium payment.



42

Combined Insurance Company of America1000 Milwaukee Avenue

Glenview, IL 60025(www.combinedinsurance.com)


Form No. 14909 First-Year Commission: 13%







Part A Deductible ($1,316): Age Area 1 Area 2 Under 65 $578.40 $525.84 65 321.60 292.32 70 420.24 382.08 75 511.32 464.88 80 578.40 525.84 85 607.32 552.12




43

Combined Insurance Company of America (continued)

Part B Excess Charges: $43.20 for all ages, all areas

Additional Home Health Care: Age Area 1 Area 2 Under 65 $111.00 $99.96 65 61.68 55.44 70 80.64 72.60 75 98.04 88.20 80 111.00 99.96 85 116.52 104.76

Foreign Travel Emergency: $32.16 for all ages, all areas

Rates for tobacco users are higher outside of open enrollment period.


44

Gerber Life Insurance CompanyP.O. Box 2271

Omaha, NE 68103-2271


Form No. MTG28-22238 First-Year Commission: 28%


Area 1: Zip Codes 539-543, 545-548Area 2: Zip Codes 530(01-04,06,09-11,13-16,18-21,23,26-27,29,31-32,34-36,38-

40,42,44,47-50,56-66,69-70,73-75,78-83,85-86,88,90-91,93-95,98-99), 531(01,03,05,14-15,18-21,25,27-28,37-39,47-49,52-53,56-57,67-68,70,76,78-79,81,83-85,90-92,95,99), 535, 537-538, 544, 549

Area 3: Zip Codes 530(05,07-08,12,17,22,24,33,37,45-46,51-52,72,76,89,92,97), 531(02,04,08-10,22,26,29-30,32,40-44,46,50-51,54,58-59,71-72,77,82,86-89,94), 532, 534







45

Gerber Life Insurance Company (continued)


Part A Deductible ($1,316): Area 1 Area 2 Area 3 Age Male Female Male Female Male FemaleUnder 65 $636.63 $553.87 $700.30 $609.25 $763.96 $664.65 65 270.81 235.60 297.90 259.16 324.98 282.72 70 318.21 276.84 350.04 304.53 381.85 332.21 75 375.84 326.98 413.42 359.68 451.01 392.38 80 431.28 375.21 474.40 412.74 517.53 450.26 85 485.15 422.08 533.66 464.29 582.18 506.50





46

Gerber Life Insurance Company (continued)


Rates for tobacco users are higher outside of open enrollment period.Different premiums for each age between age 65 and 85.Policy fee or administrative fee charged with initial enrollment.


47

Globe Life and Accident Insurance Company3700 South Stonebridge Drive

P.O. Box 8080McKinney, TX 75070

(www.globecaremedsupp.com)


Form No. GMC4810 First-Year Commission: None

Waiting Period: 60 Days Premiums are based on attained age.

Annual Premium - Basic Policy Annual Premium - All Options Age Amount Age Amount Under 65 $3,529.00 Under 65 $4,232.00 65 1,411.00 65 1,792.00 70 1,771.00 70 2,244.00 75 1,977.00 75 2,542.00 80 2,123.00 80 2,794.00 85 2,123.00 85 2,794.00

Annual Premium - Optional BenefitsPart A Deductible ($1,316): Age: Under 65 $537.00 65 217.00 70 308.00 75 398.00 80 500.00 85 500.00

Part B Deductible ($183): $165.00 for all ages

Part B Excess Charges: Age: Under 65 $11.00 65 9.00 70 10.00 75 10.00 80 10.00 85 10.00

Additional Home Health Care: $7.00 for all ages

Foreign Travel Emergency: Age: Under 65 $2.00 65 2.00 70 2.00 75 4.00 80 8.00 85 8.00Different premiums for each age between age 65 and 85.Discount offered for Electronic Funds Transfer (EFT) premium payment.



48

Government Personnel Mutual Life Insurance CompanyP.O. Box 2271

Omaha, NE 68103-2271(www.gpmlife.com)


Form No. MTP28-22760 First-Year Commission: 15%



40,42,44,47-50,56-66,69-70,73-75,78-83,85-86,88,90-91,93-95,98-99), 531(01,03,05,14-15,18-21,25,27-28,37-39,47-49,52-53,56-57,67-68,70,76,78-79,81,83-85,90-92,95,99), 535, 537-538, 544, 549

Area 3: Zip Codes 530(05,07-08,12,17,22,24,33,37,45-46,51-52,72,76,89,92,97), 531(02,04,08-10,22,26,29-30,32,40-44,46,50-51,54,58-59,71-72,77,82, 86-89,94), 532, 534






49

Government Personnel Mutual Life Insurance Company (continued)








50

Government Personnel Mutual Life Insurance Company (continued)



Part B copayment or coinsurance rider offered.Rates for tobacco users are higher outside of open enrollment period.Different premiums for each age between age 65 and 85.Policy fee or administrative fee charged with initial enrollment.


51

Greek Catholic Union of the U.S.A.5400 Tuscarawas Road

Beaver, PA 15009(www.gcuusa.com/)


Form No. 95020 WI First-Year Commission: 26.5%







Part A Deductible ($1,316): Area 1 Area 2 Age Male Female Male Female Under 65 $713.85 $620.73 $830.06 $721.79 65 237.95 206.91 276.69 240.60 70 269.04 233.95 312.84 272.03 75 334.79 291.12 389.29 338.51 80 419.65 364.92 487.97 424.33 85 513.73 446.73 597.36 519.45



52

Greek Catholic Union of the U.S.A. (continued)







53

Gundersen Health Plan, Inc.1900 South AvenueLa Crosse, WI 54601(myseniorchoice.org)


Form No. 2017.WI_MedSupp.Cert First-Year Commission: 15%


Area 1: Buffalo, Crawford, Grant, Jackson, La Crosse, Monroe, Richland, Sauk, Trempealeau, and Vernon Counties

Area 2: Milwaukee, Ozaukee, Washington, Waukesha, Racine, and Kenosha CountiesArea 3: All other Wisconsin CountiesArea 4: Policyholders who relocate out of state


Area 1 Area 1 Age Amount Age Amount Under 65 $3,332.88 Under 65 $4,363.32 65 1,110.96 65 1,546.44 70 1,379.64 70 1,901.88 75 1,718.16 75 2,356.92 80 2,038.08 80 2,808.00 85 2,370.48 85 3,300.00

Area 2 Area 2 Under 65 $3,999.48 Under 65 $5,208.36 65 1,333.20 65 1,828.20 70 1,655.52 70 2,254.68 75 2,061.84 75 2,800.80 80 2,445.72 80 3,342.00 85 2,844.60 85 3,932.52




54

Gundersen Health Plan, Inc. (continued)




Part A Deductible ($1,316): Age Area 1 Area 2 Area 3 Area 4 Under 65 $414.00 $496.80 $438.84 $579.60 65 138.00 165.60 146.28 193.20 70 186.36 223.68 197.52 260.88 75 254.76 305.76 270.00 356.64 80 340.56 408.72 360.96 476.76 85 454.20 545.04 481.44 635.88


Part B Excess Charges: Age Area 1 Area 2 Area 3 Area 4 Under 65 $148.68 $178.44 $157.56 $208.20 65 49.56 59.52 52.56 69.36 70 61.56 73.92 65.28 86.16 75 76.44 91.68 81.00 107.04 80 90.24 108.24 95.64 126.36 85 103.80 124.56 110.04 145.32

Additional Home Health Care: Age Area 1 Area 2 Area 3 Area 4 Under 65 $186.12 $223.32 $197.28 $260.52 65 62.04 74.40 65.76 86.88 70 77.04 92.40 81.72 107.88 75 95.88 115.08 101.64 134.28 80 113.88 136.68 120.72 159.48 85 132.36 158.88 140.28 185.28


55

Gundersen Health Plan, Inc. (continued)

Foreign Travel Emergency: Age Area 1 Area 2 Area 3 Area 4 Under 65 $143.64 $172.32 $152.28 $201.12 65 47.88 57.48 50.76 67.08 70 59.28 71.16 62.88 83.04 75 73.68 88.44 78.12 103.20 80 87.24 104.64 92.52 122.16 85 101.16 121.44 107.28 141.60

Part B copayment or coinsurance rider offered.Rates for tobacco users are higher outside of open enrollment period.Different premiums for each age between age 65 and 85.Part A Deductible (50%) offered.


56

Humana Insurance Company500 West Main StreetLouisville, KY 40202(www.humana.com)


Form No. WI-MESM10 Basic First-Year Commission: 8%


Area 1: Kenosha, Milwaukee, Ozaukee, Racine, Washington, and Waukesha CountiesArea 2: Brown, Dane, and Outagamie CountiesArea 3: All other Wisconsin Counties







57

Humana Insurance Company (continued)







58



Part B copayment or coinsurance rider offered.Rates for tobacco users are higher outside of open enrollment period.Different premiums for each age between age 65 and 85.Multi-policy household discount offered.Part A Deductible (50%) offered.Discount offered for Electronic Funds Transfer (EFT) premium payment.


59



Form No. WI-MESM1050; WI-MESM1025 First-Year Commission: 8% 50% Cost-Sharing Plan 25% Cost-Sharing Plan




Annual Premium - Basic Policy Annual Premium - All Options Area 1 Area 1 Age Male Female Age Male FemaleUnder 65 $2,859.24 $2,859.24 Under 65 $3,018.00 $3,018.00 65 1,143.48 1,141.20 65 1,207.08 1,204.68 70 1,391.40 1,348.80 70 1,468.68 1,423.92 75 1,693.08 1,563.60 75 1,787.04 1,650.48 80 2,000.64 1,777.68 80 2,111.76 1,876.56 85 2,319.36 1,962.24 85 2,448.48 2,071.44

Area 2 Area 2Under 65 $2,417.40 $2,417.40 Under 65 $2,551.68 $2,551.68 65 966.84 964.80 65 1,020.60 1,018.44 70 1,176.36 1,140.36 70 1,241.64 1,203.84 75 1,431.36 1,321.92 75 1,510.80 1,395.36 80 1,691.40 1,502.88 80 1,785.36 1,586.52 85 1,960.92 1,658.88 85 2,070.12 1,751.16




60

Humana Insurance Company (continued)You will pay 50% of the cost-sharing of some covered services until you reach the calendar year out-of-pocket limit of $5,120 which will increase each year for inflation. Once you reach the annual limit, the policy pays 100% of your Medicare copayment and coinsurance for the rest of the calendar year.







61

Humana Insurance Company (continued)Annual Premium - Optional Benefits


Rates for tobacco users are higher outside of open enrollment period.Different premiums for each age between age 65 and 85.Multi-policy household discount offered.Discount offered for Electronic Funds Transfer (EFT) premium payment.


62



Form No. WI MESM10HD First-Year Commission: 8%




Area 1 Area 2 Age Male Female Age Male Female Under 65 $1,883.52 $1,883.52 Under 65 $1,592.40 $1,592.40 65 788.40 786.60 65 666.60 665.04 70 946.56 919.08 70 800.28 777.12 75 1,139.28 1,056.36 75 963.24 893.16 80 1,335.84 1,192.92 80 1,129.44 1,008.48 85 1,539.48 1,311.12 85 1,301.64 1,108.56

Area 3 Under 65 $1,678.08 $1,678.08 65 702.48 700.80 70 843.36 818.88 75 1,014.96 941.16 80 1,190.16 1,062.72 85 1,371.60 1,168.08


Rates for tobacco users are higher outside of open enrollment period.Different premiums for each age between age 65 and 85.Multi-policy household discount offered .Discount offered for Electronic Funds Transfer (EFT) premium payment.



63

Humana Insurance Company(Healthy Living)

500 West Main StreetLouisville, KY 40202(www.humana.com)


Form No. WI-MESHL Basic First-Year Commission: 8%









64








65



Part B copayment or coinsurance rider offered.Rates for tobacco users are higher outside of open enrollment period.Different premiums for each age between age 65 and 85.Multi-policy household discount offered.Part A Deductible (50%) offered.Discount offered for Electronic Funds Transfer (EFT) premium payment.


66

Humana Insurance Company(Healthy Living)

500 West Main StreetLouisville, KY 40202(www.humana.com)


Form No. WI-MESHL50, WI-MESHL25 First-Year Commission: 8% 50% Cost-Sharing Plan 25% Cost-Sharing Plan



Annual Premium - 50% Cost-Sharing Plan Annual Premium - Basic Policy Annual Premium - All Options






67



Annual Premium - 25% Cost-Sharing Plan Annual Premium - Basic Policy Annual Premium - All Options






68

Humana Insurance Company (continued)Annual Premium - Optional Benefits




69

Individual Assurance CompanyP.O. Box 3270

Salt Lake City UT 84110(iac-group.com)


Form No. 94070 First-Year Commission: 16%-28% depending on commission level










70

Individual Assurance Company (continued)


Additional Home Health Visits: Area 1 Area 2 Age Male Female Male Female Under 65 $67.63 $58.81 $58.07 $50.50 65 22.54 19.60 19.36 16.83 70 25.35 22.04 21.76 18.93 75 29.40 25.57 25.25 21.95 80 33.53 29.15 28.79 25.03 85 37.16 32.32 31.91 27.75




71

Manhattan Life Insurance10777 Northwest Freeway

Houston, TX 77092(familylifeins.com)


Form No. MLMSOCWI15 First-Year Commission: 29% (79 and under) 14.5% (80 and older)







Part A Deductible ($1,316): Area 1 Area 2 Age Male Female Male Female Under 65 $989.00 $860.00 $840.00 $731.00 65 330.00 286.00 280.00 243.00 70 372.00 324.00 316.00 275.00 75 463.00 404.00 393.00 343.00 80 581.00 506.00 494.00 430.00 85 711.00 619.00 604.00 526.00



72

Manhattan Life Insurance (continued)







73

Medico Corp Life Insurance CompanyP.O. Box 10482

Des Moines, IA 50306(www.gomedico.com)


Form No. MSM70W First-Year Commission: 11.4%


Area 1: Zip Code 546Area 2: Zip Codes 530, 535, 538-539Area 3: Zip Codes 537, 542, 544Area 4: Zip Code 548Area 5: Zip Codes 531, 540Area 6: Zip Codes 532, 534Area 7: Rest of State







74

Medico Corp Life Insurance Company (continued)







75



Area 4 Area 5 Area 6 Age Male Female Male Female Male FemaleUnder 65 $836.18 $836.18 $883.29 $883.29 $914.70 $914.70 65 327.83 313.46 346.30 331.12 358.61 342.89 70 299.49 287.15 316.36 303.32 327.61 314.11 75 367.46 340.89 388.16 360.09 401.96 372.89 80 438.64 415.89 463.35 439.32 479.83 454.94 85 513.97 468.37 542.93 494.75 562.23 512.34

Area 7 Age Male FemaleUnder 65 $785.15 $785.15 65 307.82 294.33 70 281.21 269.62 75 345.03 320.08 80 411.87 390.51 85 482.60 439.78


Part B Excess Charges: All Areas Age Male Female Under 65 $24.13 $24.13 65 14.20 12.73 70 15.79 14.20 75 19.22 17.01 80 22.15 19.09 85 25.09 21.18


76


Additional Home Health Care: $6.36 for all ages, all areas

Foreign Travel Emergency: Age: Under 65 $7.34 65-85 3.67

Part B copayment or coinsurance rider offered.Rates for tobacco users are higher outside of open enrollment period.Different premiums for each age between age 65 and 85.Multi-policy household discount offered.Part A Deductible (50%) offered.


77

Mutual of Omaha Insurance CompanyMutual of Omaha Plaza

Omaha, NE 68175(www.mutualofomaha.com)


Form No. MM28-24188 First-Year Commission: 15%


Area 1 Zip Codes 539-543, 545-548Area 2 Zip Codes 530(01-04,06,09-11,13-16,18-21,23,26-27,29,31-32,34-36,38-

40,42,44,47-50,56-66,69-70,73-75,78-83,85-86,88,90-91,93-95,98-99), 531(01,03,05,14-15,18-21,25,27-28,37-39,47-49,52-53,56-57,67-68,70,76,78-79,81,83-85,90-92,95,99), 535, 537-538, 544, 549

Area 3 Zip Codes 530(05,07-08,12,17,22,24,33,37,45-46,51-52,72,76,89,92,97), 531(02,04,08-10,22,26,29-30,32,40-44,46,50-51,54,58-59,71-72,77,82,86-89,94), 532, 534




Area 3 Area 3 Under 65 $4,360.00 $3,923.90 Under 65 $5,278.21 $4,771.71 65 1,895.67 1,706.06 65 2,416.64 2,196.65 70 2,042.34 1,838.18 70 2,587.13 2,349.97 75 2,372.63 2,135.49 75 2,970.66 2,695.08 80 2,812.90 2,531.51 80 3,481.85 3,155.09 85 3,228.40 2,905.54 85 3,964.18 3,589.45Rates effective January 2017


78

Mutual of Omaha Insurance Company (continued)









79

Order of United Commercial Travelers of America1801 Watermark Drive, Suite 100

Columbus, OH 43215(www.uct.org)


Form No. MSAA2010 WI First-Year Commission: 23%


Area 1 Zip Codes 530-532, 534Area 2 Rest of State




Annual Premium - Optional BenefitsPart A Deductible ($1,316): Area 1 Area 2 Age Male Female Male Female Under 65 $2,061.00 $1,794.00 $1,735.00 $1,510.00 65 760.00 662.00 640.00 557.00 70 864.00 752.00 727.00 633.00 75 1,015.00 885.00 855.00 745.00 80 1,129.00 983.00 951.00 828.00 85 1,206.00 1,050.00 1,016.00 884.00



80

Order of United Commercial Travelers of America (continued)

Part B Deductible ($183): Area 1: $165.00 for all ages Area 2: $139.00 for all ages




Part B copayment or coinsurance rider offered.Different premiums for each age between age 65 and 85.Part A Deductible (50%) offered.


81

Pekin Life Insurance Company2505 Court Street

Pekin, IL 61558(www.pekininsurance.com)


Form No. H42 First-Year Commission: 17%


Area 1: Zip Codes 539-540, 546-548Area 2: Zip Codes 535-538, 541-545, 549Area 3: Zip Code 530Area 4: Zip Codes 531-532, 534Area 5: Rest of State







82

Pekin Life Insurance Company (continued)





Part A Deductible ($1,316): Age Area 1 Area 2 Area 3 Area 4 Area 5Under 65 $668.00 $704.00 $726.00 $799.00 $835.00 65 268.00 282.00 291.00 320.00 335.00 70 316.00 333.00 343.00 377.00 394.00 75 388.00 409.00 422.00 464.00 485.00 80 454.00 479.00 494.00 543.00 568.00 85 542.00 571.00 589.00 648.00 677.00


Part B Excess Charges: Age Area 1 Area 2 Area 3 Area 4 Area 5Under 65 $42.00 $45.00 $46.00 $51.00 $53.00 65 17.00 18.00 19.00 21.00 22.00 70 19.00 20.00 21.00 23.00 24.00 75 23.00 24.00 25.00 28.00 29.00 80 25.00 26.00 27.00 30.00 31.00 85 29.00 31.00 32.00 35.00 37.00


83

Pekin Life Insurance Company (continued)

Additional Home Health Care: Age Area 1 Area 2 Area 3 Area 4 Area 5Under 65 $50.00 $50.00 $50.00 $50.00 $50.00 65 19.00 19.00 19.00 19.00 19.00 70 28.00 28.00 28.00 28.00 28.00 75 43.00 43.00 43.00 43.00 43.00 80 59.00 59.00 59.00 59.00 59.00 85 85.00 85.00 85.00 85.00 85.00


Part B copayment or coinsurance rider offered.Rates for tobacco users are higher outside of open enrollment period.Different premiums for each age between age 65 and 85.Part A Deductible (50%) offered.Discount offered for Electronic Funds Transfer (EFT) premium payment.


84

Physicians Mutual Insurance Company2600 Dodge StreetOmaha, NE 68131

(www.physiciansmutual.com)


Form No. P235 First-Year Commission: 24%


Area 1: Zip Codes 538, 545-547Area 2: Zip Codes 535, 537, 539, 540, 544, 548, 549Area 3: Zip Codes 541-543Area 4: Zip Codes 530, 531(15,20,21,25,28,37,38,47,48,56,57,76,78,84,90,91,95)Area 5: Zip Codes 531 except for those listed above and 532, 534







85

Physicians Mutual Insurance Company (P235 Attained Age continued) Annual Premium - Basic Policy Annual Premium - All Options Area 4 Area 4 Age Amount Age Amount Under 65 $3,973.92 Under 65 $5,281.32 65 1,776.12 65 2,418.48 70 2,078.64 70 2,838.24 75 2,492.76 75 3,368.52 80 2,889.48 80 3,890.16 85 3,269.40 85 4,415.04


Annual Premium - Optional BenefitsPart A Deductible ($1,316): Age Area 1 Area 2 Area 3 Area 4 Area 5Under 65 $782.40 $834.36 $886.56 $938.76 $1,043.04 65 308.64 329.16 349.80 370.32 411.48 70 398.04 424.68 451.20 477.84 530.76 75 485.16 517.44 549.84 582.12 646.80 80 578.88 617.52 656.04 694.68 771.84 85 682.20 727.68 773.28 818.76 909.72




86

Physicians Mutual Insurance Company (P235 Attained Age continued)





87





Waiting Period: None Premiums are based on issue age.








88

Physicians Mutual Insurance Company (P235 Issue Age continued) Annual Premium - Basic Policy Annual Premium - All Options Area 4 Area 4 Age Amount Age Amount Under 65 $3,973.92 Under 65 $5,281.32 65 2,070.36 65 2,816.16 70 2,406.36 70 3,258.60 75 2,748.36 75 3,711.48 80 3,059.04 80 4,144.80 85 3,416.16 85 4,632.36


Annual Premium - Optional BenefitsPart A Deductible ($1,316): Age Area 1 Area 2 Area 3 Area 4 Area 5Under 65 $782.40 $834.36 $886.56 $938.76 $1,043.04 65 387.36 413.16 439.08 464.88 516.60 70 466.68 497.76 528.84 559.92 622.20 75 548.76 585.36 621.96 658.56 731.64 80 638.64 681.12 723.72 766.32 851.52 85 733.44 782.40 831.24 880.20 977.88




89

Physicians Mutual Insurance Company (P235 Issue Age continued)





90








Age Area 1 Area 2 Area 3 Area 4 Area 5Under 65 $1,886.64 $2,012.52 $2,138.16 $2,264.04 $2,515.56 65 445.56 475.32 504.96 534.72 594.12 70 568.68 606.60 644.52 682.44 758.28 75 722.04 770.16 818.28 866.52 962.76 80 903.36 963.60 1023.84 1,084.08 1,204.56 85 1,115.16 1,189.56 1,263.96 1,338.24 1,486.92





91








Age Area 1 Area 2 Area 3 Area 4 Area 5Under 65 $1,886.64 $2,012.52 $2,138.16 $2,264.04 $2,515.56 65 567.48 605.40 643.20 681.00 756.72 70 701.76 748.56 795.36 842.16 935.76 75 861.60 919.08 976.44 1,033.92 1,148.76 80 1,041.60 1,110.84 1,180.32 1,249.80 1,388.64 85 1,241.04 1,323.72 1,406.52 1,489.20 1,654.68





92







Annual Premium - Comprehensive Plan Annual Premium - Comprehensive Plan* with Deductible Discount Rider**






93

Physicians Mutual Insurance Company (P237 Attained Age continued) Annual Premium - Comprehensive Plan Annual Premium - Comprehensive Plan* with Deductible Discount Rider**



* IncludesallbasicpolicybenefitsandalsoprovidescoverageforPartAdeductible,PartBde-ductible,PartBexcesscharges,AdditionalHomeHealthCare,andForeignTravelEmergency.

**The Deductible Discount Rider applies a $2,200 calendar year deductible to theComprehensivePolicybenefitsforthefirstfourcalendaryearsofthepolicy.Beginningwiththefifthcalendaryear,ComprehensivePolicybenefitsarepayableinfullwithnodeductible.

Ratesfortobaccousersarehigheroutsideofopenenrollmentperiod.Differentpremiumsforeachagebetweenage65and85.Multi-policyhouseholddiscountoffered.DiscountofferedforElectronicFundsTransfer(EFT)premiumpayment.


94







Annual Premium - Comprehensive Plan Annual Premium - Comprehensive Plan* with Deductible Discount Rider**






95

Physicians Mutual Insurance Company (P237 Issue Age continued) Annual Premium - Comprehensive Plan Annual Premium - Comprehensive Plan* with Deductible Discount Rider**



* IncludesallbasicpolicybenefitsandalsoprovidescoverageforPartAdeductible,PartBde-ductible,PartBexcesscharges,AdditionalHomeHealthCare,andForeignTravelEmergency.

**The Deductible Discount Rider applies a $2,200 calendar year deductible to theComprehensivePolicybenefitsforthefirstfourcalendaryearsofthepolicy.Beginningwiththefifthcalendaryear,ComprehensivePolicybenefitsarepayableinfullwithnodeductible.

Ratesfortobaccousersarehigheroutsideofopenenrollmentperiod.Differentpremiumsforeachagebetweenage65and85.Multi-policyhouseholddiscountoffered.DiscountofferedforElectronicFundsTransfer(EFT)premiumpayment.


96

Polish Falcons of America1405 West 2200 South

Salt Lake City, UT 84119(www.polishfalcons.org)


Form No. PFA10ST BASE-WI First-Year Commission: 1%-26% depending on commission level



40,42,44,47-50,56-66,69-70,73-75,78-83,85-86,88,90-91,93-95,98-99), 531(01,03,05,14-15,18-21,25,27-28,37-39,47-49,52-53,56-57,67-68,70,76,78-79,81,83-85,90-92,95,99), 535, 537-538, 544, 549

Area 3: Zip Codes 530(05,07-08,12,17,22,24,33,37,45-46,51-52,72,76,89,92,97), 531(02,04,08-10,22,26,29-30,32,40-44,46,50-51,54,58-59,71-72,77,82,86-89,94), 532, 534






97

Polish Falcons of America (continued)






Additional Home Health Visits: Area 1: $16.68 for all ages Area 2: $18.36 for all ages Area 3: $20.04 for all ages

Foreign Travel Emergency: Area 1: $14.88 for all ages Area 2: $16.32 for all ages Area 3: $17.88 for all ages


98

Polish Falcons of America (continued)



99

Reserve National Insurance Company601 East Britton Road

Oklahoma City, OK 73114(www.reservenational.com/)


Form No. MCS-WI First-Year Commission: 19%


Area 1: Zip Codes 530-534Area 2: Zip Codes 537, 543Area 3: Rest of State







100

Reserve National Insurance Company (continued)Annual Premium - Optional Benefits






101

Reserve National Insurance Company (continued)Foreign Travel Emergency: Area 1 Area 2 Area 3 Age Male Female Male Female Male FemaleUnder 65 $38.65 $33.10 $41.40 $35.35 $46.35 $40.30 65 12.70 11.05 13.80 11.60 15.45 13.25 70 14.35 12.15 15.45 13.25 17.10 14.90 75 16.55 14.90 17.65 16.00 19.85 17.65 80 18.20 15.45 19.30 16.55 22.10 18.75 85 18.75 16.55 20.40 17.65 23.20 19.85

Part B copayment or coinsurance rider offered.Rates for tobacco users are higher outside of open enrollment period.Different premiums for each age between age 65 and 85.Policy fee or administrative fee charged with initial enrollment.Discount offered for Electronic Funds Transfer (EFT) premium payment.


102

Security Health Plan of Wisconsin, Inc.1515 North Saint Joseph Avenue

Marshfield, WI 54449(https://securityhealth.org)


Form No. INS-00094 First-Year Commission: $35.00 per month






Annual Premium - Optional BenefitsPart A Deductible ($1,316): Area 1 Area 2 Age Male Female Male Female Under 65 $1,019.96 $924.32 $886.92 $803.76 65 268.96 242.88 233.88 211.20 70 359.77 325.27 312.84 282.84 75 470.58 425.45 409.20 369.96 80 615.62 556.97 535.32 484.32 85 774.73 701.32 673.68 609.84




103

Security Health Plan of Wisconsin, Inc. (continued)




Part B copayment or coinsurance rider offered.Multi-policy household discount offered.Discount offered for Electronic Funds Transfer (EFT) premium payment.


104

Standard Life and Accident Insurance Company1 Moody Plaza

Galveston, TX 77550(www.slaico.com)


Form No. 2010-1006-WI First-Year Commission: 20%


Area 1: Zip Codes 530-532Area 2: Zip Codes 534, 540, 547-548Area 3: Zip Codes 535-539, 541-545, 549Area 4: Zip Code 546







105

Standard Life and Accident Insurance Company (continued)




Part A Deductible ($1,316): Area 1 Area 2 Age Male Female Male Female Under 65 $1,349.34 $1,263.85 $1,156.58 $1,083.30 65 375.60 339.31 321.94 290.84 70 452.52 398.66 387.87 341.71 75 528.99 458.05 453.41 392.62 80 572.68 513.17 490.87 439.86 85 674.68 631.92 578.30 541.65

Area 3 Area 4 Age Male Female Male Female Under 65 $1,092.33 $1,023.12 $1,028.07 $962.94 65 304.05 274.68 286.17 258.52 70 366.32 322.73 344.78 303.74 75 428.23 370.80 403.04 348.99 80 463.60 415.42 436.33 390.98 85 546.17 511.56 514.04 481.46

Part B Deductible ($183): Age: Under 65 $215.97 65-85 150.51



106


Part B Excess Charges: (continued) Area 3 Area 4 Age Male Female Male Female Under 65 $191.83 $179.69 $180.54 $169.12 65 53.41 48.24 50.26 45.40 70 64.33 56.68 60.54 53.34 75 75.20 65.13 70.78 61.30 80 81.41 72.96 76.62 68.66 85 95.93 89.84 90.29 84.55


Area 3 Area 4 Age Male Female Male Female Under 65 $203.31 $190.45 $191.35 $179.25 65 56.58 51.14 53.26 48.13 70 68.19 60.07 64.18 56.54 75 79.71 69.00 75.02 64.94 80 86.30 77.32 81.22 72.77 85 101.65 95.21 95.67 89.61



107


Foreign Travel Emergency: (continued) Area 3 Area 4 Age Male Female Male Female Under 65 $81.29 $76.15 $76.51 $71.67 65 22.62 20.44 21.29 19.24 70 27.27 24.02 25.66 22.61 75 31.87 27.60 29.99 25.98 80 34.51 30.93 32.48 29.11 85 40.65 38.07 38.26 35.83

Part B copayment or coinsurance rider offered.Rates for tobacco users are higher outside of open enrollment period.Different premiums for each age between age 65 and 85.


108

Standard Life and Accident Insurance Company1 Moody Plaza

Galveston, TX 77550(www.slaico.com)


Form No. 2010WH-1106-WI First-Year Commission: 20%


Area 1: Zip Codes 530-532Area 2: Zip Codes 534, 540, 547-548Area 3: Zip Codes 535-539, 541-545, 549Area 4: Zip Code 546


Area 1 Area 2 Age Male Female Age Male Female Under 65 $2,144.54 $2,013.09 Under 65 $1,838.18 $1,725.51 65 625.89 570.08 65 536.48 488.64 70 744.23 661.40 70 637.91 566.91 75 861.83 752.72 75 738.71 645.19 80 929.04 837.52 80 796.32 717.88 85 1,085.90 1,020.17 85 930.77 874.43

Area 3 Area 4 Age Male Female Age Male Female Under 65 $1,736.06 $1,629.65 Under 65 $1,633.94 $1,533.78 65 506.68 461.49 65 476.87 434.34 70 602.47 535.42 70 567.03 503.92 75 697.67 609.35 75 656.63 573.50 80 752.08 677.99 80 707.84 638.11 85 879.06 825.85 85 827.35 777.27


Rates for tobacco users are higher outside of open enrollment period.Different premiums for each age between age 65 and 85.



109

State Farm Mutual Automobile Insurance CompanyOne State Farm PlazaBloomington, IL 61710(www.statefarm.com)

Consumer Service Telephone No. Contact Local State Farm Agent

Form No. 97049 HWI First-Year Commission: 16%


Area 1: Kenosha, Milwaukee, Ozaukee, Racine, Washington, and Waukesha CountiesArea 2: Rest of State




Part A Deductible ($1,316): Area 1 Area 2 Age Male Female Male Female Under 65 $1,415.00 $1,415.00 $1,312.00 $1,312.00 65 412.50 380.60 381.70 353.10 70 520.30 479.60 480.70 444.40 75 600.60 555.50 557.70 514.80 80 676.50 623.70 625.90 577.50 85 705.10 650.10 652.30 601.70

Rates effective February 2017


110

State Farm Mutual Automobile Insurance Company (continued)

Part B Deductible ($183): Not offered



Foreign Travel Emergency: Area 1 Area 2 Age Male Female Male Female All $16.50 $15.40 $15.40 $14.30

Rates for tobacco users are higher outside of open enrollment period.Different premiums for each age between age 65 and 85.


111

Thrivent Financial for Lutherans4321 North Ballard RoadAppleton, WI 54919-0001

(www.thrivent.com)


Form No. M-MW-MSWI (10) First-Year Commission: 12%


Area 1: Zip Codes 530-532, 534Area 2: Zip Codes 535, 537-549




Annual Premium - Optional BenefitsPart A Deductible ($1,316): Age Area 1 Area 2 Under 65 $740.00 $666.00 65 176.00 158.00 70 230.00 207.00 75 305.00 275.00 80 407.00 366.00 85 526.00 473.00



112

Thrivent Financial for Lutherans (Attained Age continued)


Part B Excess Charges: Age Area 1 Area 2 Under 65 $128.00 $115.00 65 31.00 28.00 70 38.00 34.00 75 46.00 41.00 80 49.00 44.00 85 50.00 45.00


Foreign Travel Emergency: Age Area 1 Area 2 Under 65 $65.00 $59.00 65 16.00 14.00 70 19.00 17.00 75 21.00 19.00 80 22.00 20.00 85 22.00 20.00

Rates for tobacco users are higher outside of open enrollment period.Different premiums for each age between age 65 and 85.Part A Deductible (50%) offered.


113

Thrivent Financial for Lutherans4321 North Ballard RoadAppleton, WI 54919-0001

(www.thrivent.com)


Form No. M-MW-MSWI (10) First-Year Commission: 12%


Area 1: Zip Codes 530-532, 534Area 2: Zip Codes 535, 537-549




Annual Premium - Optional BenefitsPart A Deductible ($1,316): Age Area 1 Area 2 Under 65 $740.00 $666.00 65 304.00 274.00 70 374.00 337.00 75 454.00 409.00 80 535.00 482.00 85 617.00 555.00



114

Thrivent Financial for Lutherans (Issue Age continued)


Part B Excess Charges: Age Area 1 Area 2 Under 65 $128.00 $115.00 65 37.00 33.00 70 44.00 40.00 75 48.00 43.00 80 49.00 44.00 85 50.00 45.00


Foreign Travel Emergency: Age Area 1 Area 2 Under 65 $65.00 $59.00 65 19.00 17.00 70 21.00 19.00 75 22.00 20.00 80 22.00 20.00 85 22.00 20.00

Rates for tobacco users are higher outside of open enrollment period.Different premiums for each age between age 65 and 85.Part A Deductible (50%) offered.


115

Unified Life Insurance Company7201 West 129th Street, Suite 300

Overland Park, KS 66213(www.unifiedlife.com)


Form No. UNBAS-WI First-Year Commission: Varies










116

Unified Life Insurance Company (continued)






117

United American Insurance Company3700 South Stonebridge Drive

P.O. Box 8080McKinney, TX 75070

(www.unitedamerican.com)


Form No. MC4810 First-Year Commission: 22%


Annual Premium - Basic Policy Annual Premium - All Options Age Male Female Age Male Female Under 65 $4,398.00 $3,825.00 Under 65 $5,245.00 $4,561.00 65 1,888.00 1,642.00 65 2,376.00 2,065.00 70 2,332.00 2,028.00 70 2,937.00 2,553.00 75 2,580.00 2,243.00 75 3,297.00 2,866.00 80 2,749.00 2,391.00 80 3,587.00 3,118.00 85 2,749.00 2,391.00 85 3,587.00 3,118.00

Annual Premium - Optional BenefitsPart A Deductible ($1,316): Age Male Female Under 65 $645.00 $561.00 65 288.00 250.00 70 404.00 351.00 75 513.00 446.00 80 629.00 547.00 85 629.00 547.00

Part B Deductible ($183): $177.00 for all ages

Part B Excess Charges: Age Male Female Under 65 $14.00 $12.00 65 12.00 10.00 70 13.00 11.00 75 13.00 11.00 80 13.00 11.00 85 13.00 11.00



118

United American Insurance Company (continued)

Additional Home Health Care: Male Female For all ages $9.00 $7.00

Foreign Travel Emergency: Age Male Female Under 65 $ 2.00 $2.00 65 2.00 2.00 70 2.00 2.00 75 5.00 5.00 80 10.00 8.00 85 10.00 8.00

Part B copayment or coinsurance rider offered .Rates for tobacco users are higher outside of open enrollment period.Different premiums for each age between age 65 and 85.


119

Western Catholic Union510 Maine StreetQuincy, IL 62301

(www.wculife.org)


Form No. WCUMSBAS-WI 08/2014 First-Year Commission: 28% maximum


Area 1: Zip Codes 539-543, 545-548Area 2: Zip Codes 530 (all others), 531(all others), 535, 537, 538, 544, 549Area 3: Zip Codes 530(05,07,08,12,17,22,24,33,37,45,46,51,52,72,76,89,92,97),

531(02,04,08-10,22,26,29,30,32,40-44,46,50,51,54,58,59,71,72,77,82,86-89,94), 532, 534







120

Western Catholic Union (continued)






121

Western Catholic Union (continued)Foreign Travel Emergency: Area 1 Area 2 Area 3 Age Male Female Male Female Male FemaleUnder 65 $28.68 $24.96 $31.68 $27.60 $34.44 $30.00 65 11.52 10.08 12.60 10.92 13.80 12.00 70 12.60 10.92 13.92 12.12 15.12 13.20 75 15.12 13.20 16.68 14.52 18.12 15.72 80 17.16 14.88 18.84 16.44 20.52 17.88 85 18.60 16.20 20.52 17.88 22.32 19.44



122

Wisconsin Physicians Service Insurance Corporation1717 West Broadway


(www.wpsic.com)


Form No. 28132-051-1601 First-Year Commission: 15%


Area 1: Zip Codes 530, 531(01-13,16-19,22-24,26-27,29-36,39-46,49-55,58-75,77,79-83,85-89,92-94,96-99), 532, 534

Area 2: Zip Codes 546 and 549Area 3: Rest of State







123

Wisconsin Physicians Service Insurance Corporation (continued)


Part A Deductible ($1,316): Age Area 1 Area 2 Area 3 Under 65 $1,018.20 $972.00 $925.68 65 357.24 340.92 324.72 70 471.60 450.24 428.76 75 585.84 559.20 532.56 80 700.32 668.40 636.60 85 814.56 777.60 740.52


Part B Excess Charges: Age Area 1 Area 2 Area 3 Under 65 $187.20 $178.68 $170.16 65 82.20 78.48 74.76 70 99.00 94.56 90.00 75 116.04 110.76 105.48 80 132.96 126.84 120.84 85 149.64 142.92 136.08



Part B copayment or coinsurance rider offered.Different premiums for each age between age 65 and 85.Multi-policy household discount offered.Part A Deductible (50%) offered.Discount offered for Electronic Funds Transfer (EFT) premium payment.


124

Wisconsin Physicians Service Insurance Corporation1717 West Broadway


(www.wpsic.com)


Form No. 29400-051-1701 First-Year Commission: 15% 50% Cost-Sharing Plan 25% Cost-Sharing Plan


Area 1: Zip Codes 530, 531(01-13,16-19,22-24,26-27,29-36,39-46,49-55,58-75,77,79-83,85-89,92-94,96-99), 532, 534

Area 2: Zip Codes 546 and 549Area 3: Rest of State


Annual Premium - Basic Policy Annual Premium - All Options Area 1 Area 1 Age Amount Age Amount Under 65 $2,203.32 Under 65 $2,227.80 65 980.88 65 1,005.36 70 1,204.80 70 1,229.28 75 1,439.76 75 1,464.24 80 1,659.12 80 1,683.60 85 1,762.32 85 1,786.80

Area 2 Area 2 Under 65 $2,103.24 Under 65 $2,127.72 65 936.36 65 960.84 70 1,149.96 70 1,174.44 75 1,374.24 75 1,398.72 80 1,583.64 80 1,608.12 85 1,682.28 85 1,706.76



125



Area 3 Area 3 Under 65 $2,003.04 Under 65 $2,027.52 65 891.72 65 916.20 70 1,095.24 70 1,119.72 75 1,308.84 75 1,333.32 80 1,508.28 80 1,532.76 85 1,602.12 85 1,626.60



Annual Premium - Basic Policy Annual Premium - All Options Area 1 Area 1 Age Amount Age Amount Under 65 $2,797.56 Under 65 $2,822.04 65 1,245.48 65 1,269.96 70 1,530.00 70 1,554.48 75 1,828.56 75 1,853.04 80 2,107.08 80 2,131.56 85 2,238.12 85 2,262.60




126





Multi-policy household discount offered.Discount offered for Electronic Funds Transfer (EFT) premium payment.

127


GROUP MEDICARE SUPPLEMENT POLICIES—TRADITIONAL INSURERS

This listing includes group plans offered through associations. You must be a member of that association in order to purchase the plan.

State of Wisconsin, Office of the Commissioner of InsuranceMedicare Supplement Insurance Approved Policies List Group Policy, Traditional Insurer

128

Aetna Life Insurance Company(American Grandparents Association)800 Crescent Centre Drive, Suite 200



Form No. GPHMSP13BC WI First-Year Commission: 15.5%


Area 1: Zip Codes 530-532, 534Area 2: Rest of State




Annual Premium - Optional BenefitsPart A Deductible ($1,316): Area 1 Area 2 Age Male Female Male Female Under 65 $1,212.00 $1,267.00 $1,054.00 $1,102.00 65 253.00 273.00 220.00 237.00 70 343.00 361.00 298.00 314.00 75 454.00 469.00 395.00 408.00 80 605.00 616.00 526.00 536.00 85 967.00 960.00 841.00 835.00




129

Aetna Life Insurance Company (American Grandparents Association continued)

Part B Excess Charges: Area 1: $52.00 for all ages Area 2: $45.00 for all ages



Part B copayment or coinsurance rider offered.Rates for tobacco users are higher outside of open enrollment period.Different premiums for each age between age 65 and 85.Policy fee or administrative fee charged with initial enrollment.Multi-policy household discount offered.Discount offered for Electronic Funds Transfer (EFT) premium payment.


130

UnitedHealthcare Insurance Company (AARP)680 Blair Mill RoadHorsham, PA 19044

(www.aarpmedicaresupplement.com)Consumer Service Telephone No. 1-800-523-5800

Form No. MDMW 0838, MDNW 0839, CRMD 05, CRMD 06, CRMD 07, CRMD 14, MAMW 0840, MANW 0841, CRMA 08, CRMA 09, CRMA 10, CRMA 15

First-Year Commission: $345 Maximum

Waiting Period: 3 Months See enrollment discount.*

Area 1: Kenosha, Milwaukee, Ozaukee, Racine, Washington, and Waukesha CountiesArea 2: Adams, Barron, Bayfield, Brown, Chippewa, Clark, Columbia, Dane, Door,

Eau Claire, Florence, Fond du Lac, Forest, Green Lake, Iron, Juneau, Lafayette, Langlade, Lincoln, Manitowoc, Marathon, Marinette, Marquette, Menominee, Oconto, Oneida, Outagamie, Pepin, Portage, Rock, Sauk, Sawyer, Sheboygan, St. Croix, Taylor, Vilas, Walworth, Washburn, Waupaca, Waushara, Winnebago, and Wood Counties

Area 3: Ashland, Buffalo, Burnett, Calumet, Crawford, Dodge, Douglas, Dunn, Grant, Green, Iowa, Jackson, Jefferson, Kewaunee, La Crosse, Monroe, Pierce, Polk, Price, Richland, Rusk, Shawano, Trempealeau, and Vernon Counties


Area 1 Area 1 Age Amount Age Amount Under 65 $4,575.00 Under 65 $5,847.00 65 1,778.64* 65 2,274.24* 70 2,159.76* 70 2,761.44* 75 2,795.04 75 3,573.84 80 2,795.04 80 3,573.84 85 2,795.04 85 3,573.84

Area 2 Area 2 Under 65 $3,705.00 Under 65 $4,737.00 65 1,440.60* 65 1,841.64* 70 1,749.24* 70 2,236.20* 75 2,263.80 75 2,894.04 80 2,263.80 80 2,894.04 85 2,263.80 85 2,894.04



131

UnitedHealthcare Insurance Company (AARP continued) Annual Premium - Basic Policy Annual Premium - All Options Area 3 Area 3 Age Amount Age Amount Under 65 $3,390.00 Under 65 $4,332.00 65 1,318.80* 65 1,684.20* 70 1,601.40* 70 2,044.92* 75 2,072.40 75 2,646.60 80 2,072.40 80 2,646.60 85 2,072.40 85 2,646.60

Annual Premium - Optional BenefitsPart A Deductible ($1,316), Part B Excess Charges, and Foreign Travel Emergency: Age Area 1 Area 2 Area 3 Under 65 $744.00 $606.00 $552.00 65 289.80 235.20 214.20 70 351.84 285.60 260.04 75 455.40 369.60 336.60 80 455.40 369.60 336.60 85 455.40 369.60 336.60

Part B Deductible ($183): Age Area 1 Area 2 Area 3 Under 65 $453.00 $366.00 $336.00 65 176.40 142.80 130.20 70 214.20 173.40 158.04 75 277.20 224.40 204.60 80 277.20 224.40 204.60 85 277.20 224.40 204.60

Additional Home Health Care: Age Area 1 Area 2 Area 3 Under 65 $75.00 $60.00 $54.00 65 29.40 23.04 21.00 70 35.64 27.96 25.44 75 46.20 36.24 33.00 80 46.20 36.24 33.00 85 46.20 36.24 33.00

Individuals applying for the UnitedHealthcare Group Medicare Supplement Policy must be members of AARP.

* Enrollment discount included in rates for age 65 and 70: insureds who are within 3 years of their 65th birthday or Part B effective date, if later; insureds between 3 years and less than 6 years of their 65th birthday or Part B effective date, if later, and meet underwriting requirement. The enrollment discount decreases by 3% each year until the enrollment discount is 0%.


132

UnitedHealthcare Insurance Company (AARP continued)

Part B copayment or coinsurance rider offered.Rates for tobacco users are higher outside of open enrollment period.Multi-policy household discount offered.Part A Deductible (50%) offered.Discount offered for Electronic Funds Transfer (EFT) premium payment.

Please contact Customer Service Toll Free number at 1-800-523-5800 for your premium rate and to determine if you are eligible for any available discounts.

133


MEDICARE SUPPLEMENT POLICIES—MEDICARE SELECT

Medicare select policies are offered by HMOs and PPOs. HMOs are prepaid health plans. You pay the HMO a set premium each month for all covered services. You must use the doctors and hospitals that are connected to the plan. There is less paperwork if you join an HMO. PPOs will provide reduced benefits if you receive care from providers who are not connected to the plan. All Medicare select policies contain similar benefits and these benefits are included in the basic policy.

State of Wisconsin, Office of the Commissioner of InsuranceMedicare Supplement Insurance Approved Policies List Medicare Select

134

Dean Health Plan, Inc.1277 Deming WayMadison, WI 53717

(www.deancare.com)


Form No. 6999-1216 First-Year Commission: None


Area: Adams, Columbia, Crawford, Dane, Dodge, Fond Du Lac, Grant, Green, Green Lake, Iowa, Jefferson, Juneau, Kenosha, Lafayette, Marquette, Racine, Richland, Rock, Sauk, Vernon, Walworth, Washington, and Waukesha Counties

Annual Premium - Basic Policy

Age Amount

Under 65 $2,652.00 65 1,728.00 70 2,064.00 75 2,592.00 80 3,024.00 85 3,396.00

Part A Deductible ($1,316): In basic policy

Part B Deductible ($183): In basic policy

Additional Home Health Care: In basic policy

Foreign Travel Emergency: In basic policy



135

Group Health Cooperative of South Central Wisconsin1265 John Q. Hammons Drive

Madison, WI 53717(www.ghcscw.com)


Form No. CSC16-28-08-1(08/16/)F First-Year Commission: 10%


Area: Dane, Jefferson, Green, Lafayette, Rock, Columbia, Dodge, Iowa, Sauk, Adams, Richland, Vernon, and Juneau Counties


Age Amount

Under 65 $2,833.80 65 2,046.84 70 2,519.76 75 3,068.52 80 3,326.52 85 3,326.52







136

Health Tradition Health Plan1808 East Main StreetOnalaska, WI 54650

(www.healthtradition.com)

Consumer Service Telephone No. 1-888-459-3020 or 1-608-781-9692

Form No. 221HTH207 First-Year Commission: 15%


Area: Buffalo, Crawford, Grant, Jackson, Juneau, La Crosse, Monroe, Richland, Sauk, Trempealeau, and Vernon Counties


Age Amount

Under 65 $2,451.48 65 1,622.28 70 2,076.36 75 2,452.80 80 2,803.20 85 3,114.72







137

MercyCare HMO, Inc.580 North Washington Street

P.O. Box 550Janesville, WI 53547-0550

(www.mercycarehealthplans.com)


Form No. MCSPNOV2013 First-Year Commission: None


Area 1: Rock, Walworth, and Green CountiesArea 2: Jefferson County


Area 1 Area 2 Age Amount Amount

Under 65 $2,280.00 $2,752.80 65 1,500.00 1,988.04 70 1,740.00 2,421.36 75 1,980.00 2,663.52 80 2,160.00 2,994.84 85 2,400.00 3,555.60





Different premiums for each age between age 65 and 85.



138

Physicians Plus Insurance Corporation2650 Novation Parkway, Suite 400

Madison, WI 53713(pplusic.com)

Consumer Service Telephone No. 1-608-282-8900 or 1-800-545-5015

Form No. P+6004 First-Year Commission: $20.05


Area: Adams, Columbia, Crawford, Dane, Dodge, Grant, Green, Green Lake, Iowa, Jefferson, Juneau, LaFayette, Marquette, Richland, Rock, Sauk, Vernon, and Waushara Counties


Age Male Female

Under 65 $2,952.00 $2,640.00 65 1,824.00 1,572.00 70 1,956.00 1,776.00 75 2,256.00 2,028.00 80 2,688.00 2,388.00 85 3,060.00 2,880.00







139

Security Health Plan of Wisconsin, Inc.1515 North St. Joseph Avenue

Marshfield, WI 54449(https://securityhealth.org)


Form No. INS-00016 First-Year Commission: $35.00 per month


Area: Adams, Ashland, Barron, Bayfield, Burnett, Chippewa, Clark, Douglas, Dunn, Eau Claire, Forest, Iron, Jackson, Juneau, Langlade, Lincoln, Marathon, Monroe, Oneida, Pepin, Portage, Price, Rusk, Sawyer, Shawano, Taylor, Trempealeau, Vilas, Washburn, Waupaca, Waushara and Wood Counties

Annual Premium - Basic Policy Age Amount Under 65 $3,384.00 65 1,854.00 70 2,550.00 75 3,186.00 80 3,636.00 85 4,404.00





Discount offered for Electronic Funds Transfer (EFT) premium payment.



140

Unity Health Plans Insurance Corporation840 Carolina StreetSauk City, WI 53583

(https://unityhealth.com)


Form No. UH00804 First-Year Commission: $3.00 per month


Area: Adams, Columbia, Crawford, Dane, Dodge, Fond du Lac, Grant, Green, Green Lake, Iowa, Jefferson, Juneau, Lafayette, Marquette, Richland, Rock, Sauk, Vernon, Walworth, Waushara, and Waukesha Counties


Age Male Female Under 65 $3,240.00 $2,952.00 65 1,716.00 1,680.00 70 2,040.00 1,920.00 75 2,376.00 2,184.00 80 2,868.00 2,520.00 85 3,276.00 3,048.00






141


MEDICARE COST INSURANCE

Medicare cost insurance is a special arrangement between the federal Centers for Medicare & Medicaid (CMS) and certain HMOs. The HMO agrees to provide Medicare benefits. The HMO may provide additional benefits at additional cost.

Medicare cost insurance will only pay full supplemental benefits if covered services are obtained through HMO plan providers. You must live in the plan service area to apply for Medicare cost insurance. The HMO plan providers are selected by the HMO.

In a Medicare cost insurance policy you are not “locked in” to the HMO plan providers for your Medicare benefits. Medicare will still pay its share of approved charges if the services you receive outside the network are services covered by Medicare. If you go to a health care provider who does not belong to your HMO without a referral from your HMO physician, you will pay for all Medicare deductibles and copayments. The HMO will not provide supplemental benefits.

State of Wisconsin, Office of the Commissioner of InsuranceMedicare Supplement Insurance Approved Policies List Medicare Cost Insurance

142

HealthPartners Insurance Company8170 33rd Avenue South

P.O. Box 1309Minneapolis, MN 55425

(healthpartners.com/medicare)

Consumer Service Telephone No. 1-800-247-7015, TTY 711

Form No. EOC-200.16 COST WI BA RXD First-Year Commission: Contact plan EOC-200.16 COST WI BA EOC-200.16 COST WI B

Waiting Period: None Premiums are not based on age.

Area: Barron, Burnett, Douglas, Dunn, Pierce, Polk, St. Croix, and Washburn Counties

Annual Premium

Type of Policy Amount WI Freedom Balance with Rx $1,849.20 WI Freedom Balance 1,188.00 WI Freedom Basic 720.00

Part A Deductible ($1,316): In all policies

Part B Deductible ($183): In all policies

Additional Home Health Care: In WI Freedom Balance with Rx and WI Freedom Balance policies

Foreign Travel Emergency: In WI Freedom Balance with Rx and WI Freedom Balance policies



143

Medica Insurance Company401 Carlson Parkway

Minnetonka, MN 55305(www.medica.com/medicare)


Form No. WI-PRI-EOC-17-100-01 First-Year Commission: $25.00 - $34.00


Area: Ashland, Barron, Bayfield, Burnett, Chippewa, Douglas, Dunn, Eau Claire, Pierce, Polk, Sawyer, St. Croix, and Washburn Counties

Annual Premium

Type of Policy Amount Thrift Policy $ 588.00 Value Policy 804.00 Basic Policy 948.00 Enhanced Policy 1,884.00







144

Medical Associates Clinic Health Plan of Wisconsin1605 Associates Drive

Dubuque, IA 52002(www.mahealthcare.com)


Form No. Y0045 H5256 PBP 004_MAHP 784 First-Year Commission: $18.00 Y0045 H5256 PBP 002_MAHP 783 Y0045 H5256 PBP 001_MAHP 782


Area: Crawford, Grant, Iowa, and Lafayette Counties

Annual Premium

Type of Policy Amount Freedom Plan $1,896.00 Community Plan 1,656.00 Smart Plan 1,296.00

Part A Deductible ($1,316): In all policies

Part B Deductible ($183): In all policies

Additional Home Health Care: In all policies

Foreign Travel Emergency: In all policies


Documents

Medicare Supplement Insurance Approved Policies List (PI-010)